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Dec 06 07 02: 56p Afforda Test, [209) 744-0116 p. 2 SWRCB,January 2002 [',age�L-of Secondary Containment esting Report Form This form is intended for use by contractors perfurminK periodlc testing of WT secont&uy containment systems. Use the appropriate pages ofthisfoem to report resulisfor all components tested. The completed form, written test procedures, and printouts from tests flfapplicable), should be provided to the facility owner/operator for submittal to the local regulatory agency, I. FACILITY INFORMATI0N Faciti Namc:�I—LJQ r, �.YG) Date ofTesting; ll 04 I'acility Address. I .,S 4- L-&C�W,-O 5 ?5 O Facility Contact: `s-tfC Cts--� Q Rr�C" PltonC: 2.d $,Sg 7.16 6,6 Date Local Agency Was l otificd of Testing: N1-151010 Name of Local Agency Inspector ftf present during testing): 2. TESTING CONTRACTOR INIF0"ATI0N Company Name: A w• i Gun. •es-S4-t 'Technician Conducting Test: r,�,�,,., F, .�_—..._--�---..._._._.---_.__ �._�__..._..._.......... .....__...__---- Credentials: n CSLB Licensed ontractor WRCB Licensed Tank Tester License Type: �,,,� L T^r5�-��Y .. �~ l.Ge'nse Number: 1910- 11'2-0 ManafRS.urer'Training Manufacturer _..�......-__.Coanponent(s) Date Training F.X ires 3. '.SUMMARY OF TEST RESiJLTS Component pada Fait Not Repairs Component Paas Fail Not Repairs Tested de Tested Made 4f r zt/c j- U ❑ oU iq e -S se C¢ ❑ ❑ rl r a�.K#� ❑ ❑ ❑ UAqe 7f $ 0 ❑ ❑ uv e,r V-re 73 1.1 U L 1 U U ❑ ❑ Sectdw �� U U U ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ r # Cl Cl 0 D ❑ ❑ ❑ tl tA 3 ❑ I."1 I:1 ❑ ❑ ❑ T U ❑ Cl ❑ ❑ ❑ ❑ ❑ if hydrostatic testing was performed,describe what was done with the water after completion of tests: 3 CEtrTIF ICATION 010M CIINICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowled a facts stated In this t are accurate and In full compliance with legal requirements Technician's Signatu Date: r Z�j j J0 C7